TESOL Certificate Checklist Graduate Advanced TESOL Certificate Program Application Save my progress and resume later | Resume a previously saved formResume LaterIn order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Page 1Advanced TESOL Certificate CampusPortland Program of StudyPlease select...Graduate Advanced TESOL Certificate Admission forPlease select...Fall 2019 (August) First Name Middle Name Last Name Preferred First Name (If Different) Have you gone by any other legal names? (such as a maiden name) Email Cell Phone Home Phone Allow Text MessagesAllowDo Not Allow Mailing Address CityPlease select...AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVTWAWIWVWYOutside the USAAAEAPASDCFMGUPWVI State Zip CodeEthnic & Racial Information (Optional) Are you Hispanic/Latino?YesNoOptional - this information will not be a factor in your admission decision Please select one or more of the following races:American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or CaucasianOptional - this information will not be a factor in your admission decisionAdditional Personal Information Are you a U.S. Citizen?YesNo Are you a U.S. Permanent Resident?YesNoAn international student is one who will be attending a university in the United States without residency or citizenship, typically on an F-1 visa. International students have additional application requirements as part of the Visa application process, often including an English language proficiency exam and transcript evaluation by an evaluation service. The admissions department can assist with questions about this process. Country of CitizenshipPlease select...United States of AmericaCanadaAfghanistanAlbaniaAlgeriaAndorraAngolaAntiguaArgentinaArubaAustriaAustraliaAzoresBahamasBahrainBalearic IslandsBangladeshBarbadosBelgiumBelizeBeninBermudaBhutanBoliviaBotswanaBrazilBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanal ZoneCanary IslandsCape Verde IslandsCayman IslandsCentral African RepublicChadChilePeoples' Republic of ChinaColombiaComoro IslandsCongoCook IslandsCorsicaCosta RicaCote d'IvoireCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEnglandEquatorial GuineaEstoniaEthiopiaEast TimorFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuinea-BissauGuineaGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKoreaKuwaitLaosLatviaLebanonLeeward IslandsLesothoLiberiaLibyaLiechtensteinLithuaniaLaosLuxembourgMacaoRepublic of MacedoniaMadeira IslandsMalagasyMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMexicoFederated States MicronesiaMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherland AntillesNetherlandsNevisNew BritainNew CaledoniaNew HebridesNew ZealandNicaraguaNigerNigeriaNorth KoreaNorthern IrelandNorwayOkinawaPakistanPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPrincipeQatarReunion IslandsRomaniaRussiaRwandaRyukyu IslandsSaudi ArabiaSouth AfricaScotlandSenegalSeychelles IslandsSierra LeoneSikkimSingaporeSouth KoreaSlovakiaSloveniaSolomon IslandsSomoliaSpainSpanish North AfricaSpanish SaharaSri LankaSanta Cruz IslandsSt. KittsSt. LuciaSt. ThomasSt. VincentSudanSultanate of OmanSurinameSouthwest AfricaSwazilandSwedenSwitzerlandSouth YemenSyriaTaiwanTanzaniaThailandTobagoTogoTongaTrinidadTurks IslandTunisiaTurkeyTuvaluUgandaUnited KingdomUkraineUnited Arab EmiratesUruguayVatican CityVenezuelaVietnamVirgin IslandsWalesWindward IslandsWestern SamoaYemenYugoslaviaZaireZambiaZimbabwe Date of Birth GenderFemaleMaleHousehold Marital StatusPlease select...SingleMarriedSeparatedDivorcedWidow/WidowerSpouse Information Relationship to youPlease select...Spouse First Name Last Name EmailPlease note: This email address should not match the email given for other individuals on this application. Entering the same email address as the applicant or other individuals on this form may result in a technical error. Does this person share your mailing address?YesNo Mailing Address CityPlease select...AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVTWAWIWVWYOutside the USAAAEAPASDCFMGUPWVI State Zip CodeHidden Fields Student (Record Type) Constituent (Record Type) TypePlease select...Christian Character ReferenceChristian Character Reference Graduate and Seminary Household (Record Type) Educational Institution (Record Type)Page 2Academic HistoryCollege Have you completed a bachelor's degree?YesNoI will prior to beginning this program Have you completed at least 12 college level, foreign language credits?Please select...YesNoI will prior to beginning this programCollege or Graduate SchoolPlease list all institutions you have attended, beginning with the most recent. Institution Name City StatePlease select...AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVTWAWIWVWYOutside the USAAAEAPASDCFMGUPWVI Attended from: Attended to: Are you currently enrolled at this institution?YesNo Approximate Credits Earned Degrees earned:Lifestyle Responsibilities Have you used illegal substances within the last year?YesNo Please explain Have you pled guilty (or no contest), been adjudicated, or otherwise been convicted of a crime or subject to a civil indictment or other disciplinary action? YesNo Do not include infractions such as speeding tickets.Please note that offers of admission may be revoked should additional information arise that indicates unlawful or unethical behavior.Criminal or Disciplinary Disclosure & Authorization to Release InformationBecause you indicated that you have a civil or criminal indictment, conviction, history and/or disciplinary action on this application, you will be asked to complete a background check once all of your application materials are received and processed.A previous disciplinary action, conviction, indictment or prosecution may not automatically bar an applicant from admissions to the university. We request that the applicant provide the Admissions Office permission to obtain a background check (at no cost to the student). By electronically signing below, the applicant authorizes Multnomah University to have complete access to pertinent educational, employment, criminal and civil information and records: Name: Date signed: Please provide a complete and detailed explanation regarding any civil or criminal indictment, conviction, history and/or disciplinary action: Multnomah's Doctrinal StatementMultnomah University welcomes students from a variety of denominational backgrounds. The University holds to a short list of doctrinal articles. Though it does not require students to be in agreement with all points, it is important that you be familiar with the university’s doctrinal statement, found at www.multnomah.edu/about/doctrinal-statement. I have read Multnomah's doctrinal statement and I am comfortable studying at an institution that holds to these positions.YesNo If not, please explain Have you committed your life to Jesus Christ as your personal Savior?YesNoUnsure Please explainChurch Involvement Name of the Church you regularly attend DenominationPlease select...Non-DenominationalAmerican BaptistAssembly of GodAmerican Missionary FellowshipAnglicanBaptistBibleBrethrenCatholic BelieverCatholicConservative BaptistChurch of ChristCongregationalChristianChristian & Missionary AllianceCommunityCovenantEvangelical Church of North AmericaEvangelical FreeEpiscopalFree MethodistFriendsFoursquareGeneral Conference BaptistChurch of GodIndependentInd Fundamental Churches of AmericaInterdenominationalJewish BelieverJewishLutheranMennonite BrethrenMethodistNazarenePlymouth BrethrenPentecostalPresbyterianProtestant BelieverProtestantRegular BaptistRoman CatholicReformedSouthern BaptistSeventh Day AdventistUnknownVillage MissionsWesleyan Methodist Please explain City, StateEssayPlease submit an essay of at 300-500 words describing your relationship with Jesus Christ, and why you are interested in participating in the TESOL Advanced Certificate Program. Please enter your essay here:Page 3Christian Character ReferencePlease provide the name and contact information for somebody who can serve as your Christian Character Reference. The admissions team will email your reference a form to complete on your behalf. This form should be completed by the your pastor, church leader, spiritual mentor, or a Christian who knows you well and can speak to your testimony and walk with Christ. It should not be completed by a relative.Your application file is not considered complete until a Christian Character Reference form has been received by the University's Admissions Office. Name First Name Last Name Phone EmailPlease note: This email address should not match the email given for other individuals on this application. Entering the same email address as the applicant or other individuals on this form may result in a technical error. In some circumstances, we may ask for an additional reference. If this is the case, your admissions counselor will let you know and request the additional information. Reference AuthorizationBy providing this information I am authorizing Multnomah to contact the person listed above as my Christian Character Reference. I understand that the information provided by my reference will be used as part of the admission decision process, and I waive my right to review this information.Decision Factors How did you first hear about Multnomah?Please select...AlumniAdmissions CounselorCollege FairCo-worker or EmployerCurrent MU StudentFriendGuidance Counselor or TeacherGoogle SearchMU Faculty or StaffParent or RelativePastorRadioVisit to my high schoolWeb advertisementOther Explain What is the primary factor influencing your decision to apply?Please select...Academic Programs OfferedAcademic ReputationAdmissions CounselorAlumniBeliefs/ValuesCampus EventCampus VisitClassmateCollege FairCo-worker or EmployerFriendGuidance CounselorLocationMail or email communicationMU Faculty or StaffOther Explain Name of the person who referred you (so we can thank them)Certification & Authorization $40 Application FeeI will pay my application fee online now using a credit or debit cardI will mail a check or money order for my application feeOtherYou can pay your application fee by check or money order mailed to:Admissions OfficeMultnomah University8435 NE Glisan StreetPortland OR 97220You may pay your $40 application fee at www.multnomah.edu/payments.Links:Mission StatementStudent Life HandbookHuman Sexuality and Purity Understanding By submitting this application, I certify that I have provided complete and accurate statements on this application and I waive my right to see reference forms that are submitted on my behalf. I understand that if it is found to be otherwise, this may be cause for rejection or dismissal. I agree with the mission, goals, and core values of Multnomah University. I agree to abide by the guidelines, principles, and regulations published in the Multnomah catalog and student handbook. I understand that Multnomah seeks to be an alcohol-free, tobacco-free, drug-free, and sexually pure campus and I agree to live according to the Human Sexuality and Purity Understandings.YesNo Please type your full name in this box as a signature certifying the preceding statements are accurate and complete, to the best of your knowledge. Save my progress and resume later | Resume a previously saved form Need assistance with this form?